Wessex Academic Health Science Network (WAHSN), on behalf of the AHSN Network, led work to develop the NHS Business Services Authority (BSA) Polypharmacy Prescribing Comparators (the Comparators) to help CCGs and GP Practices understand variation in prescribing of multiple medicines and enable identification of patients most likely to be exposed to risks associated with taking multiple medicines or certain combinations of medicines.
Polypharmacy is an ongoing challenge for the NHS; problematic polypharmacy describes when people experience problems with the number of medicines they are taking and/or clinical challenges around the combination of medicines they are taking. The error rate in prescribing increases with increasing medication load. Problematic polypharmacy significantly affects older people: up to a third of those over 75 are taking seven or more medicines and more at risk of harm and avoidable hospital admission(s).
The Comparators are now a nationally available data tool (and the only such tool in England) showing variation in prescribing but also offering GP Practices and CCGs a practical way to identify patients deemed to be at greatest risk from harm. Our data shows that were used to full effect, CCGs and GP Practices can reduce the rate of polypharmacy in patients at greatest risk.
6.5% of hospital admissions are for adverse effects of medicines, rising to 17% in over 65s. 70% of these could be avoided if problematic polypharmacy is addressed. There is poor public awareness of the harm caused, despite anyone taking ten or more medications being 300% more likely to be admitted to hospital.
Problematic polypharmacy is a challenge for both patient and healthcare provider. Historically, prescribing data in England has focussed on cost and volume. WAHSN led the first work programme with the NHS BSA to link the NHS Number to the medicines prescribed. This revolutionary dataset was developed to be of value to clinicians trying to address polypharmacy, benefitting patients at greatest risk.
In developing the Comparators, WAHSN led a group of analysts and clinicians from Wessex and North East and North Cumbria AHSNs, NHS BSA, NHS Digital, local GPs, Pharmacists, prescribing analysts, clinical specialists and the Royal Pharmaceutical Society. Before launch, each Comparator was validated nationally by members from a wide range of all NHS healthcare sectors.
This created the first national polypharmacy dataset in England and supported NHS England in its contribution to the WHO global challenge to address polypharmacy as a major cause of medication errors.
The NHS BSA Polypharmacy Prescribing Comparators are available to CCGs and GP Practices across England. As of May 2019 there are 5,900 registered users, including pharmacists who work across a number of practices.
The Comparators enable GP Practices and CCGs to;
- See variation in prescribing across GP Practices, within and across CCGs
- Identify if polypharmacy is an area to be investigated in the practice or CCG
- Help prioritise potential areas of activity and better target areas where improvement is needed to reduce the risk to patients.
CCGs such as Wakefield and North East Hampshire & Farnham (NEH&F) have supported practices to identify their patients at increased risk and, by acting on the data, have now reduced these rates at double the national rates of reduction.
In NEH&F CCG, with the support of a Care Homes Pharmacist, there have been over 250 medication reviews and 800 interventions leading to a decrease in the average number of medicines per patient from 9.4 to 7.6. GP Practices such as Westbourne Medical Practice have been able to demonstrate how the tool enabled them to review patients and reduce polypharmacy with 94% of patients having their medications optimised following their identification using the database.
The Comparators were developed in a multi-stakeholder collaborative environment both locally and nationally; consensus and buy-in were generated throughout the project. CCGs and GP Practices can use the Comparators to generate and shape their work on polypharmacy, which is a complex and multifaceted issue, supported by the AHSN(s).
Since the official launch in 2017, WAHSN has continued to engage closely with its local stakeholders, offering essential ‘post-implementation’ support to drive the meaningful use of the Comparators and empower local teams to ultimately benefit patients by reducing polypharmacy and its associated risks. WAHSN has provided local GP Practices with individualised reports detailing their performance against the Comparators.
These ‘data packs’ enable individual prioritisation but also peer-to-peer comparison and WAHSN sees them as a tool ripe to ‘start a conversation’ in a safe sharing environment. Problematic polypharmacy does not sit in isolation and the Comparators have become invaluable in engaging stakeholders more deeply on polypharmacy.
As an example, locally we have identified that GPs need support in better understanding high-risk medications and their risk in older people. This has helped develop e-learning modules on University Hospital Southampton’s Medicines Information e-learning portal
Nationally, there are 5,900 registered users of the NHS BSA Polypharmacy Prescribing Comparators. Locally, NEH&F CCG has had a full-time Care Homes Pharmacist using the database and undertaking face-to-face medication reviews with residents in conjunction with GPs. 250 reviews were conducted with over 800 resulting interventions with an average number of medicines per patient reduced from 9.4 to 7.6 and the average anticholinergic burden score reduced from 1.39 to 1.00.
GP Practices such as Westbourne Medical Practice have demonstrated how the tool has enabled them to review patients and reduce prescribing, with 94% of patients having their medications optimised following their identification using the database and invitation to participate in a 30-minute consultation.
A current evaluation with the NIHR will formally establish the value of the Comparators and their impact on certain clinical outcomes. To date, local teams have been given the time to make the Comparators work in their own setting – changing behaviour and practice key to the longer-term adoption and widespread use of the Comparators.
Locally, more and more CCGs and GP Practices are using the platform as part of their broader polypharmacy efforts, with WAHSN supporting these teams and ensuring the learning is being shared and captured.
By identifying patients deemed to be at risk of harm from problematic polypharmacy, the Comparators allow individuals to understand their polypharmacy burden and target efforts towards addressing this. The Comparators, part of a complex whole, are simple to use. GPs and Pharmacists working in GP Practices and CCG medicines teams can review their data compared with local, regional and national levels.
Practices can use the data to identify the patients at greatest risk from harm. In NEH&F, GPs have worked with the CCG Care Home Pharmacist to identify patients at greatest risk and conduct medication reviews and adjust patient regimens accordingly. The CCG team has written a standard email request for GP Practices to use when requesting the NHS Numbers of patients from NHS BSA.
GP Practices such as Westbourne Medical Practice found that, through using the Comparators, medication regimens were optimised with a fifth of patients having a high-risk medicine associated with preventable drug-related admissions stopped, the medication review process also being highly rated by patients.
This model of care further supports the RCGP recommendation to prioritise the care of patients living with multiple long-term conditions by adopting face-to-face dedicated reviews incorporating the skills of GPs and practice-based Pharmacists.